How do I get an urgent (expedited) appeal?
Say the words "expedited appeal" and state that waiting the standard time could seriously jeopardise your life, health or ability to regain maximum function, or would subject you to severe pain; if a treating physician says the claim is urgent, the plan must treat it as urgent. Decisions are due within 72 hours, and you can request expedited external review at the same time.
What to do, in order
- Step 1
Make the request by phone and in writing
Plans must accept urgent requests orally. Call, use the word expedited, then send the same request in writing the same day with the claim number.
- Step 2
Get the physician's statement
A treating physician's statement that the standard timeframe would seriously jeopardise health or cause severe pain makes the claim urgent by rule; the plan cannot override it.
- Step 3
Ask for simultaneous external review
For urgent care, you may request expedited external review at the same time as the internal appeal. Say so in the request.
- Step 4
Hold the plan to the clock
72 hours for the decision, and the plan must tell you what is missing within 24 hours if the request is incomplete. Note the times.
The deadline that applies
Urgent care claims: decision within 72 hours of receipt; missing information notified within 24 hours; expedited appeal decided within 72 hours (29 CFR 2560.503-1; 45 CFR 147.136). Medicare Advantage expedited reconsiderations: 72 hours (42 CFR 422.584). Part D expedited redeterminations: 72 hours (42 CFR 423.584).
Calculate your date →Documents to gather
- The written expedited request with the claim number and the reason it is urgent
- The treating physician's urgency statement
- The denial or pending request
- A log of the times of each call and notice
Go deeper
Related questions
Can a post-service claim be expedited?
No. Expedited handling is for care not yet received or ongoing. A claim for care already given follows the standard timeframe.
What if the plan says it is not urgent?
If a treating physician has said it is, the plan must treat it as urgent. Send the statement and cite the rule.
Does expedited mean a lower bar?
No. Same criteria, faster clock, and the same right to the criteria and the claim file.
Sources
Upload the denial letter. A senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.
Start a free denial review →